Posted: May 1st, 2022

Episodic/Focused SOAP Note Chest Pain

Well being Assessment

Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date

Well being Assessment
Episodic/Focused SOAP Note Chest Pain
S.
CC: “Chest ache”

HPI: Mr. Foster is a 55-year-old Caucasian male that seems comparatively wholesome and energetic. He’s seen at this time for brand spanking new onset of chest ache. The chest ache started a couple of month in the past and its non-radiating. The ache is localized to the middle of his chest. He denies ache within the arms, legs and jowl ache. The affected person denies signs of nausea, vomiting, dizziness and shortness of breath. Mr. Foster denies numbness or tingling of the extremities and denies belly ache throughout the episodes. The chest ache is “uncomfortable” and hurts within the middle of his chest. The ache is described as “tight, tightness” that offers him “nervousness when it doesn’t subside.” Mr. Foster charges the chest ache a 5 out 10 depth on a 1-10 ache scale. The affected person states the chest ache episodes have occurred about 3 times within the final month. The ache is triggered by bodily exercise like climbing stairs or yard work and appears to final for a couple of minutes. The chest ache subsides after a interval of relaxation. Mr. Foster states he had a traditional EKG carried out about three months in the past.

S.
PMx: Optimistic for hypertension and hyperlipidemia identified 1 12 months in the past.

ROS:
Normal: Affected person seems wholesome, presents with no ache or signs presently.
AAOx4, denies complications or facial ache, seizures, dizziness, numbness or tingling of extremities and denies lack of sensation.
HEENT: Denies visible or listening to deficit, Denies loud night breathing, insomnia, or sleep apnea, Denies problem of swallowing
RESP: Denies shortness of breath, Bronchial asthma and denies COPD
CV: Denies murmur, earlier chest ache, denies diaphoresis,
GI: Denies coronary heart burn or gastrointestinal points, denies adjustments or irregular bowel actions
DIET: Adverse for coronary heart nutritious diet (steak, purple meats)
GU: Denies problem with urination, denies prostate issues and is sexually energetic
MUS/SKE: Denies joint, muscle, leg, toes or hip ache
SKIN: Denies pores and skin deformities or pores and skin illnesses

PSx: Denies surgical procedure of any variety.

ADULT
ILLNESS: Denies hospitalization, damaged bones or any grownup sickness. Denies infections, flu, pneumonia or having shingles. Optimistic for childhood rooster pox.
IMMUNIZATION: Updated, wants annual flu shot

ALLERGIES: Codeine: Causes nausea and vomiting
MEDICATIONS: *Lisinopril (Prinivil) 20 mg, PO Every day, taken at this time
*Atorvastatin (Lipitor) 20 mg, PO Every day at bedtime, final dose yesterday (hyperlipidemia)
*Omega Three Fish Oil 1200 mg PO BID, final dose at 8am (OTC Complement).

FHx: Mom; kind 2 diabetes, hypertension, age 80.
Father: hypertension, hyperlipidemia, weight problems, died at 75 of colon most cancers.
Brother: died at 24 MVA.
Sister: kind 2 diabetes, hypertension, at 52.
Maternal grandmother: died of coronary heart assault.
No historical past of untimely heart problems in first diploma kinfolk.
S.
SHx : Adverse for present or earlier tobacco use; consumes 2-Three alcohol drinks every week; denies use of marijuana, cocaine, heroin or different illicit medicine up to now thirty years. Faculty graduate and employed full time as civil engineer and comfy with monetary state of affairs. Affected person studies being married for 27 years and has two kids. He lives at dwelling together with his spouse and daughter. He enjoys spending time with household and is bodily energetic with chores and every day job like yard work. He doesn’t have a routine train routine.
ROS
Normal– Affected person seems wholesome and neurological intact. The affected person is AAOx4 and strikes all extremities. The affected person performs ADL independently. The affected person presents with no chest ache or signs of chest ache presently. Face is symmetrical, pores and skin is dusky to pale on his face and hair is plentiful all through head. The affected person is just not sporting any visible aids corresponding to glasses or listening to aids. The affected person is unfavourable for dyspnea at relaxation, chills, fatigue, and is afebrile.
Pulmonary: No irregular visible findings. No cough or hemoptysis. Chest is symmetrical, no intercostal respiratory seen. Trachea is midline. Inspected bilaterally arms and toes with no visible cyanosis, no clubbing of nails, no irregular colour famous of extremities on inspection. No obvious indicators of shortness of breath. Chest rise is equal upon inhale and exhale.
CV: Inspected neck for jugular venous distention. JVP Three cm above sternal angle. Chest is symmetrical and no abnormalities noticed. Affected person is afebrile, with no generalized edema. Higher and decrease extremities are pink, toenails aren’t thickened and seem wholesome. Upon inspection of decrease extremities, the left and proper legs seem to haven’t any hair current. Decrease extremities are with out edema and pores and skin colour is pink.
GI: Stomach is barely rounded with no irregular pores and skin deformities upon examination. Inspected entrance, proper and left sides of stomach and no irregular findings upon visible examination. Adverse for nausea, vomiting, coronary heart burn or gastrointestinal points.
GU: No abnormalities in urination and continence.

O.
VS: BP (Rt Arm), Sitting 146/90; P (Monitor) 104; R 19; T 37.four; 02. 98%
Wt. 197 lbs.; Ht 5 ft 11 inches

Bodily Examination
GENERAL: Affected person is just not at the moment having chest pains and is asymptomatic. Affected person is neurologically intact, AAOx4, with no obvious bodily deficit.
HEENT: Face is symmetrical with no facial droop. No glasses, listening to aids and breaths effectively by way of his nostril. Speech is evident.
NECK:
Trachea is midline. No plenty palpated. Carotid arteries: Auscultated left and proper carotid pulse with bell of stethoscope. Left bruit current, Proper Bruit current. Palpated left and proper carotid pulse; BL No thrill, +2 left, +Three Proper. Inspected neck for jugular venous distention, JVP Three cm above sternal angle.

CHEST:
HEART: Auscultated pulmonic, aortic, Erbs level and tricuspid space with diaphragm first then used the bell on every space listed. S1, S2 heard on the apex and base of the guts. S3, gallop auscultated with the bell and heard at cardiac apex. No different advinticous sounds upon auscultation.
PMI: Palpated PMI, Displaced laterally; brisk and tapping lower than Three cm
LUNGS: Breath sounds in all areas of lungs posterior and anterior. Anterior RUL, RLL clear. Anterior LLL, LUL all clear. Posterior RUL, LUL clear upon auscultations. Advantageous crackles posterior LLL and posterior RLL upon auscultation.
ABDOMEN: Adverse bruit upon of belly aorta upon auscultation. The precise and left belly arteries are unfavourable for bruits with bilaterally equal pulses upon auscultation. Iliac pulse bilaterally with no bruits discovered upon auscultation. Bilaterally femoral pulses audible with no bruits heard upon auscultation.
Belly bowel sounds audible in all 4 quadrants upon auscultation. Tympany over the stomach as percussed.
Stomach palpation with mild and deep stress in LLQ, RLQ, URQ, ULQ. No irregular findings. No plenty, guarding, tenderness or distention upon palpation.
LIVER: Adverse for friction rub as auscultated over liver. Palpable 1 cm beneath proper costal margin. Liver span 7cm within the midclavicular line with dullness current upon percussion.
SPLEEN: Auscultation over spleen and no friction rub discovered upon examination. Not palpable, no plenty or splenomegaly are famous. Percussion stays tympanic as percussed.
KIDNEYS: Left kidney, not palpable, proper kidney, not palpable.
SKIN: Heat, dry, non-tenting and regular for ethnicity. .
PERIPHERAL VASCULAR PULSES:
Brachial pulse palpable bilaterally. Brachial pulse left; No thrill +2, Brachial pulse proper: No thrill +2. Radial Pulses: Bilaterally, No thrill +2 left and proper upon palpation.
Femoral Pulses: Bilaterally equal with no thrill +2, left and proper upon palpation.
Popliteal Pulses: Bilaterally palpable with variations famous: Proper, No thrill +2, LEFT No thrill, +1 diminished and barely palpable.
Tibial Pulses: Bilaterally equal palpable with no thrill and +1 diminished on left and proper.
Dorsalis pedis pulse: Bilaterally equal upon palpation. No thrill, +1 diminished and barely palpable left and proper.
Diagnostic outcomes: EKG, CXR, CK-MB. EKG shows QRS adjustments. The abnormalities within the coronary heart rhythm recommend some parts of the guts aren’t getting adequate blood (Joloudari et al., 2020). CXR reveals the form and measurement of the guts to find out if coronary heart is enlarged as a result of a situation (Cagle Jr & Cooperstein, 2018). CK–MB isoenzyme take a look at values reveals presence of abnormalities.
Blood take a look at to test levels of cholesterol, coronary calcium scan, CT Cornary angiogram or catherization lab to see the extent of potential blockage, echocardiogram stress take a look at to find out blood circulate (Alizadehsani et al., 2019).
A.
Differential Prognosis:
1) CAD – CAD signs and Mr. Foster signs extraordinarily comparable. CAD is widespread and he has hyperlipidemia and hypertension (Alizadehsani et al., 2019). The commonest symptom of CAD is chest ache described in Mr. Fosters’ interview. CAD may very well be a participant in Mr. Fosters’ signs. Different proof that results in CAD is the S3 gallop heard throughout the examination in addition to a speedy coronary heart price of 104. Angina ache, pulses in his extremities aren’t all equal and lots of are faint to barely palpable. He is also lacking hair on his legs which leads towards peripheral vascular points r/t CAD.
2) Angina – Is widespread and is relieved with nitro or relaxation. We will carry out a stress take a look at to see the really stress on the guts and check out nitro when the ache happens since we all know relaxation relieves the ache (Hu et al., 2018).
Three) CHF – His blood stress is excessive systolic and diastolic in addition to pulse is excessive. His coronary heart is working onerous and he has fantastic crackles within the bases of his lungs LLL LRL bilaterally which might point out fluid buildup r/t CHF (Hu et al., 2018). I really feel strongly he’s on this class based mostly on the proof introduced in his examination
Want extra take a look at like stress take a look at to find out how onerous his coronary heart is working whereas he’s bodily energetic. We want a doable echocardiogram to measure his cardiac output or ejection fraction. We want a troponin and CK enzymes drawn even when the final assault was greater than 24 hours. These take a look at can resolve if he has coronary heart muscle injury, MI or underlying coronary heart points.
Major Prognosis/Presumptive Prognosis:
Coronary Artery Illness
P.
Therapy plan entails taking treatment since it’s the first line of remedy of CAD. Nitroglycerin tablets controls the ache and dilating the coronary arteries. The treatment reduces the guts’s demand for blood (Chandra et al., 2017). The affected person ought to make way of life adjustments together with keep away from smoking, consuming alcohol, begin exercising, and eat wholesome meals. A daily analysis is important to find out the extent of danger.

References
Alizadehsani, R., Roshanzamir, M., Abdar, M., Beykikhoshk, A., Khosravi, A., Panahiazar, M., … & Sarrafzadegan, N. (2019). A database for utilizing machine studying and information mining methods for coronary artery illness prognosis. Scientific Knowledge, 6(1), 1-13.
Cagle Jr, S. D., & Cooperstein, N. (2018). Coronary Artery Illness: Prognosis and Administration. Major Care, 45(1), 45.
Chandra, D., Gupta, A., Chief, J. Okay., Fitzpatrick, M., Kingsley, L. A., Kleerup, E., … & Sciurba, F. C. (2017). Assessment of coronary artery calcium by chest CT in contrast with EKG-gated cardiac CT within the multicenter AIDS cohort examine. PloS One, 12(four), 0176557.
Hu, T., Yang, C., Lin, S., Yu, Q., & Wang, G. (2018). Biodegradable stents for coronary artery illness remedy: Current advances and future views. Supplies Science and Engineering: C, 91, 163-178.
Joloudari, J. H., Hassannataj Joloudari, E., Saadatfar, H., GhasemiGol, M., Razavi, S. M., Mosavi, A., … & Nadai, L. (2020). Coronary artery illness prognosis; rating the numerous options utilizing a random bushes mannequin. Worldwide Journal of Environmental Analysis And Public Well being, 17(Three), 731.

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